- Email: [email protected]
S.18.01 Electroconvulsive therapy (ECT)
S190
S.18 Interventional treatments in depression: latest outcome data
[2] Jureidini, J.N., Doecke, C.J., Mansfield, P.R., Haby, M.M., Menkes, D.B., Tonkin, A.L., 2004. Efficacy and safety of antidepressants for children and adolescents. BMJ 328, 879−83. [3] Ryan N.D., 2005. Treatment of depression in children and adolescents. The Lancet. 366, 933–940.
S.17.05 Is there place for pharmacology in the treatment of childhood anxiety disorders? B. Vitiello ° . National Institute of Mental Health, Room 7147, Bethesda, USA Anxiety disorders constitute the most common form of psychopathology in childhood. While in many cases the symptoms resolve either spontaneously or with minimal supportive treatment, in other cases the disorder persists in time, causes significant suffering and functional impairment, and leads to more serious psychopathology, such as depression, in adolescence. Cognitivebehavioral therapy (CBT) is the staple of the treatment of anxiety disorders in childhood. CBT has been specifically manualized for the treatment of children with obsessive-compulsive disorder (OCD) and social phobia. Serotonin reuptake inhibitors, including clomipramine and the selective serotonin reuptake inhibitors (SSRIs), have been found to be effective in decreasing anxiety symptoms in childhood OCD. A number of SSRIs have been shown to be effective in the treatment of children with social phobia, generalized anxiety disorder, and separation anxiety (RUPP Anxiety Study Group 2001). The SSRI efficacy is supported by multiple placebo controlled clinical trials, thus meeting the highest standard of evidence-based medicine and leading to the conclusion that the risk/benefit ratio of pharmacological treatment of childhood anxiety disorders is favorable. There is evidence that the combined use of SSRI medication and CBT is more effective than medication monotherapy in childhood OCD (Paediatric OCD Treatment Study, 2004). For other anxiety disorders, a multisite clinical trial is currently in progress to compare monotherapy with combined treatment. Pharmacotherapy represents a valuable option for the treatment of childhood anxiety disorders, especially when CBT is not sufficient. References [1] RUPP Anxiety Study Group, 2001. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344:1279– 1285. [2] Pediatric OCD Treatment Study, 2004. Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized, controlled trial. JAMA 292:1969–1976.
S.18 Interventional treatments in depression: latest outcome data S.18.01 Electroconvulsive therapy (ECT) T. Bolwig ° . Copenhagen University Hospital, Rigshospitalet, Department of Psychiatry, Copenhagen, Denmark ECT is the hitherto most powerful treatment of severe melancholic depression [1]. It is further highly efficacious in the therapy of mania, catatonia, delirium and malignant neuroleptic syndrome. ECT is associated with fewer severe complications than any other
intervention given during universal anaestesia. ECT is increasingly used as an out-patient treatment in drug-therapy resistant depression, resistance occurring in 30−40%. After some decades of effective anti-ECT lobbying ECT usage has been greatly limited. This is partly for ideological reasons, partly because ECT induces transient memory impairment of some duration, which has misled to the erroneous idea of brain damage being the result of ECT. During the last few years this situation however seems to have changed considerably. The working mechanism of ECT is not clarified, the involvement of transmitter and receptor biology seems similar to that induced by antidepressant drugs, and also to alternative brain stimulation methods such as rTMS and VNS. These latter methods have antidepressant effects, but are so far therapeutically weaker in severe depression than ECT. rTMS and VNS in animal studies are similar to experimental ECT, only their influence on hippocampal biology, especially neurogenesis is weaker. This may well be due to the lack of seizures, which seem to represent the motor of the therapeutic process induced by ECT [2]. References [1] UK ECT Review Group (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and metaanalysis. Lancet 361: 799–808. [2] Bolwig, T.G. (2003). Putative common pathways in therapeutic brain stimulation for affective disorders. CNS Spectrums 8(7): 490–495.
S.18.02 Vagus nerve stimulation: the heart and guts of the matter M. Trimble ° . The National Hospital, Institute of Neurology, London, United Kingdom Amongst the newer treatments for depression and mood instability is Vagus Nerve Stimulation (VNS). As experience is gathered it seems that VNS is not a classical antidepressant, and patients who are most appropriately assigned VNS treatment have treatment resistant depression, an entity which is recognised but rather poorly defined. Extensive data on the use of VNS in epilepsy are available which led to observations of improvements of mood in that population. Thus, VNS may be seen as another example of a therapy which appears anticonvulsant, but also beneficial to patients with mood disorders. From completed trials of VNS in patients with treatment resistant depression, some interesting features with regards to response are noted, in particular the increase in the number of responders and remitters over a 12 month period. Thus, greater improvements are noted at 12 months in comparison with 3 months. Stimulation of the vagus nerve may be of importance for mood. Patients with VNS implants have been studied using fMRI while carrying out memory tasks comparing performance during stimulation with no stimulation. The results suggest that stimulation interferes with memory for negative emotional stimuli. The vagus nerve is important for feeling good, for having a good heart and satisfied guts. This finding has led to the formulation of a neurovegetative hypothesis of VNS function in mood disorders.
S.18 Interventional treatments in depression: latest outcome data
[2] Jureidini, J.N., Doecke, C.J., Mansfield, P.R., Haby, M.M., Menkes, D.B., Tonkin, A.L., 2004. Efficacy and safety of antidepressants for children and adolescents. BMJ 328, 879−83. [3] Ryan N.D., 2005. Treatment of depression in children and adolescents. The Lancet. 366, 933–940.
S.17.05 Is there place for pharmacology in the treatment of childhood anxiety disorders? B. Vitiello ° . National Institute of Mental Health, Room 7147, Bethesda, USA Anxiety disorders constitute the most common form of psychopathology in childhood. While in many cases the symptoms resolve either spontaneously or with minimal supportive treatment, in other cases the disorder persists in time, causes significant suffering and functional impairment, and leads to more serious psychopathology, such as depression, in adolescence. Cognitivebehavioral therapy (CBT) is the staple of the treatment of anxiety disorders in childhood. CBT has been specifically manualized for the treatment of children with obsessive-compulsive disorder (OCD) and social phobia. Serotonin reuptake inhibitors, including clomipramine and the selective serotonin reuptake inhibitors (SSRIs), have been found to be effective in decreasing anxiety symptoms in childhood OCD. A number of SSRIs have been shown to be effective in the treatment of children with social phobia, generalized anxiety disorder, and separation anxiety (RUPP Anxiety Study Group 2001). The SSRI efficacy is supported by multiple placebo controlled clinical trials, thus meeting the highest standard of evidence-based medicine and leading to the conclusion that the risk/benefit ratio of pharmacological treatment of childhood anxiety disorders is favorable. There is evidence that the combined use of SSRI medication and CBT is more effective than medication monotherapy in childhood OCD (Paediatric OCD Treatment Study, 2004). For other anxiety disorders, a multisite clinical trial is currently in progress to compare monotherapy with combined treatment. Pharmacotherapy represents a valuable option for the treatment of childhood anxiety disorders, especially when CBT is not sufficient. References [1] RUPP Anxiety Study Group, 2001. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344:1279– 1285. [2] Pediatric OCD Treatment Study, 2004. Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized, controlled trial. JAMA 292:1969–1976.
S.18 Interventional treatments in depression: latest outcome data S.18.01 Electroconvulsive therapy (ECT) T. Bolwig ° . Copenhagen University Hospital, Rigshospitalet, Department of Psychiatry, Copenhagen, Denmark ECT is the hitherto most powerful treatment of severe melancholic depression [1]. It is further highly efficacious in the therapy of mania, catatonia, delirium and malignant neuroleptic syndrome. ECT is associated with fewer severe complications than any other
intervention given during universal anaestesia. ECT is increasingly used as an out-patient treatment in drug-therapy resistant depression, resistance occurring in 30−40%. After some decades of effective anti-ECT lobbying ECT usage has been greatly limited. This is partly for ideological reasons, partly because ECT induces transient memory impairment of some duration, which has misled to the erroneous idea of brain damage being the result of ECT. During the last few years this situation however seems to have changed considerably. The working mechanism of ECT is not clarified, the involvement of transmitter and receptor biology seems similar to that induced by antidepressant drugs, and also to alternative brain stimulation methods such as rTMS and VNS. These latter methods have antidepressant effects, but are so far therapeutically weaker in severe depression than ECT. rTMS and VNS in animal studies are similar to experimental ECT, only their influence on hippocampal biology, especially neurogenesis is weaker. This may well be due to the lack of seizures, which seem to represent the motor of the therapeutic process induced by ECT [2]. References [1] UK ECT Review Group (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and metaanalysis. Lancet 361: 799–808. [2] Bolwig, T.G. (2003). Putative common pathways in therapeutic brain stimulation for affective disorders. CNS Spectrums 8(7): 490–495.
S.18.02 Vagus nerve stimulation: the heart and guts of the matter M. Trimble ° . The National Hospital, Institute of Neurology, London, United Kingdom Amongst the newer treatments for depression and mood instability is Vagus Nerve Stimulation (VNS). As experience is gathered it seems that VNS is not a classical antidepressant, and patients who are most appropriately assigned VNS treatment have treatment resistant depression, an entity which is recognised but rather poorly defined. Extensive data on the use of VNS in epilepsy are available which led to observations of improvements of mood in that population. Thus, VNS may be seen as another example of a therapy which appears anticonvulsant, but also beneficial to patients with mood disorders. From completed trials of VNS in patients with treatment resistant depression, some interesting features with regards to response are noted, in particular the increase in the number of responders and remitters over a 12 month period. Thus, greater improvements are noted at 12 months in comparison with 3 months. Stimulation of the vagus nerve may be of importance for mood. Patients with VNS implants have been studied using fMRI while carrying out memory tasks comparing performance during stimulation with no stimulation. The results suggest that stimulation interferes with memory for negative emotional stimuli. The vagus nerve is important for feeling good, for having a good heart and satisfied guts. This finding has led to the formulation of a neurovegetative hypothesis of VNS function in mood disorders.